Checklists are Standard for Cockpit Safety: Why not for Critical Care?

As HEMS Crews, we often operate in some of the most challenging and austere environments in medicine. Whether on the side of a highway, the back of the local BLS Ambulance, or a small community hospital, we often provide care in less than ideal surroundings. As HEMS crews, we pride ourselves on our airway management skills, and many times airway management is the reason we are requested. However, over the years prehospital intubation and RSI has been called into question for many reasons, ranging from prolonged scene times in trauma to high incidence of failed airways. The other argument that is made is that intubation is a low-volume, high-risk procedure. Locally each base, on average does three to five intubations a month which works out to less than one intubation per provider per month. Do you think less than twelve intubations a year is enough to maintain proficiency? I do not know the answer to that question, and no one has any clinical evidence either way. However, I do know I want to do everything in my power to optimize my success.

One of the ways to improve success is with a “Challenge and Response” RSI checklist. We all know aviation checklists are a foundation of pilot standardization and cockpit safety. It’s a way to combat fatigue and as a cognitive aid during high-stress high-intensity situations. The concepts of cognitive offloading have recently become popular as health care becomes much more complex and reimbursement becomes increasingly tied to performance. In fact, the World Health Organization says “Human error in the complex world of modern medicine is inevitable.” Harm to patients as the result of these errors is not. Checklists allow complex pathways of care to function with high reliability by giving users the opportunity to pause and take stock of their actions before proceeding to the next step.” So, in addition to all the standard airway training avenues such as cadaver labs, videos, articles and practice with “Fred the Head” I thought I would try adding a “challenge and response” checklist to my practice. I want to share the process by which I developed the checklist and how I employed it with my partners.

I am a big proponent of Free Open Access Medical Education (FOAMed). The idea of an RSI checklist/dump kit has been bouncing around that community for some time. Dr. Cliff Reed and the folks from Sydney HEMS already had their checklist openly available with a ton of education to go along with it. Here is the Sydney HEMS checklist:

Sydney HEMS did an amazing job developing their checklist, but we needed to modify a few things just to bring it in line with our protocols. So we went through it, line by line with some of the crews and added things like, push does pressors, post intubation sedation, BVM with PEEP, ETCO2 etc.. Here is the final product:

As you can see the checklist is very simple, and it was not designed to be a “cheat sheet” for airway evaluation, medication doses, or difficult airway algorithms. This was done purposefully, because according to Nagano, the checklist should be seen as relevant and useful, rather than a nuisance task.[1] The checklist was designed to verify critical preparation after it’s been done; it was not designed to be used before/during the preparation. We are all expected to know how to set-up for an RSI, without consulting a checklist. The checklist is used as a rapid “time-out” before induction, to correct any omissions.

In practical terms, once the decision to perform an RSI, patient positioning and preoxygenation are done while medications and equipment are prepared. Once the crew feels like everything is ready and the patient is adequately preoxygenation, crew 2 calls out each line on the checklist. Crew 1 responds by either confirming (“check”, “got it”) or explaining what the plan is for that particular item (“Jonny the firefighter is going to hold c-spine”, “we are going to use 200mg/4 ml of ketamine and 100mg/10 ml or Rocuronium”). While you and your partner may already have a shared vision of how the RSI will go, an added advantage to the checklist is, verbalizing your shared vision and plan with whoever is there to assist with the intubation. It also incorporates the mandatory medication cross-checks. This whole process typically takes 45-60 seconds.

So in conclusion, if our pilots use a checklist for startup, a procedure which they do a couple of hundred times a year, why would we not use a checklist for something we do less than twelve times a year. The checklist was never designed to replace years of experience, hours of training, or critical thinking. In fact, the exact opposite; it’s designed to enhance the skills we have all spent so much time developing.

About the Author:

Sam Matta is a nurse/medic with PHI Air Medical, working in Baltimore, MD for the University of Maryland ExpressCare 1 Flight Team. He started his nursing career with the US Army in Iraq and continues to have a passion for emergency/critical care medicine, since the start of his career. Sam has a particular interest in airway management, mechanical ventilation, and ECMO/E-CPR. He recently became the Director of HEMS forEast Coast Helicopter Operations(ECHO), responsible for the education of flight crews from across the country.

ECHO offers FREE education by Flight Crews for Flight Crews and is gearing up for their annual conference in Athens. Ga, October 11-13, 2016. This three-day training event will involve Pre-Conference training events for all flight disciplines. It’s open to all public safety / military flight crew ECHO members for FREE. Clickhere, for more information and registration.